Records Management – MA Book – Chapter 13 – Flashcards
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Medical Records
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Legal documents - spelling counts; Patient History; Family history; Religious beliefs; Ethnic beliefs; Cultural beliefs
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Charting
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Progress notes
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EHR
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Electronic Health Records
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EMR
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Electronic Medical Records
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Electronic Health Records
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Contains insurance and medical history
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Electronic Medical Records
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Contains medical history (diagnosis, treatment, etc.)
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Medicaid and Medicare
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Controlled by CMS
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CMS
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Center for Medicare and Medicaid Services
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Meaningful Use
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Governed by CMS; If doctor accepts a patient, at the end of the year the office will receive an "incentive bonus"
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Certified MA can
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Order labs; Phone in prescriptions; Order X-Rays
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Parts of a medical record
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Administrative data; Financial and insurance information; Correspondence; Referral; Past medical records; Clinical data; Progress notes; Diagnostic information; Lab information; Medications
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Subjective Information
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What the patient states
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Objective Information
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What is found
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Progress notes
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documents the progress of the patient; contains chief complaint
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Chief Complaint (CC)
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the main reason for seeking medical care
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Two popular charting methods
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POMR; SOAP
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Problem-Oriented Medical Record
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POMR
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POMR
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Begins with the standard database information; then lists chronic problems with dates of service for each problem; last medication lists, preventative lists, and education information given to the patient.
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Subjective-Objective Assessment Plan
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SOAP
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SOAP
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Subjective impressions; Objective clinical evidence; Assessment or diagnosis; Plans for further studies, treatment, or management
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CHEDDAR
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Chief Complaint; History; Examination; Details of problems and complaints; Drugs/Dosages; Assessment; Return visit
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When to use CHEDDAR
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To ensure you've charted with needs to be charted
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History Physical Impression Plan
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HPIP
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HPIP
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History (subjective findings); Physical exam (objective findings); Impression (assessment/diagnosis); Plan (treatment)
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Health Insurance Portability and Accountability Act
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HIPAA
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HIPAA
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Legal requirements regarding patient privacy rights
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Steps for proper records
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1. Read accurately and spell names correctly 2. Print or write legibly with black ink 3. Record information as soon as possible 4. Make corrections by drawing one line through the error 5. Keep charts neat and file in a timely manner
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Filing systems
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Chronological Alphabetically Numeric Subject
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Steps in filing
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1. Inspect 2. Index 3. Code 4. Sort 5. Store
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Inspecting
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Look for anything abnormal in the reports
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Indexing
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Categories
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Coding
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Index identifier
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Sorting
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After it is coded, put it in order
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Storing
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Put it away
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Outguide
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Patient's Name Patient's Address Patient's DOB Who has patient's record
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Purge
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To clean out
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Unit (when indexing)
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One (patient) name
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Last name
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Surname
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Review of Symptoms
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ROS
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Who do records belong to?
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The office
